Does percutaneous dilatational tracheostomy increase the incidence of sternal wound infection - a single center retrospective of 4100 cases

Journal of Cardiothoracic Surgery

Ajay Moza¹  Rüdiger Autschbach¹  Andreas Goetzenich¹  Jan Spillner¹  Helga Haefner²  Rachad Zayat¹  Lachmandath Tewarie¹ 

[1] Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany;Department of Infection Control and Infectious Diseases, University Hospital RWTH Aachen, Aachen, Germany

关键词: Postoperative complication;    Cross-infection;    Sternal Wound Infection (SWI);    Cardiac surgery;    Percutaneous Dilatational Tracheostomy (PDT);    Mediastinitis;   

Others  :  1232264
DOI  :  10.1186/s13019-015-0365-z

 received in 2015-05-13, accepted in 2015-10-28,  发布年份 2015

【 摘 要 】

Background

The impact of percutaneous dilatational tracheostomy (PDT) on the development of post-median sternotomy wound infection (SWI) and mediastinitis is still controversial. We aimed to investigate the frequency of cross-infection and incidence of SWI after PDT.

Methods

In a retrospective design, out of a total of 4100 procedures, all patients who had undergone median sternotomy and postoperative PDT were included from January 2010 to May 2013. For comparison of the pathogens isolated from SWIs, data from all patients who developed an SWI without a PDT during the aforementioned period were also analyzed. Demographical, pre-, peri- and post-operative data were compared. Microbiologic analysis from cultures of sternal and tracheal wounds was performed. Day and duration of tracheostomy were correlated to SWI occurrence.

Results

Of the 265 patients who underwent a PDT, 25 (9.4 %) developed an SWI. In this cohort, identical pathogens were isolated from the tracheostomy and SWI in 36 % (9/25) of the patients. Of the pathogens isolated from the SWIs from the PDT + SWI group, 60 % were gram-positive bacteria, 20 % gram-negative bacteria and 20 % Candida spp. In the cross-infection group, the patients developed the following types of SWIs: 11.1 % CDC I, 55.6 % CDC II and 33.3 % mediastinitis (CDC III). The incidence of SWI in the group SWI + PDT was 9.4 % (9.4 % vs. 3.4 %, PDT + SWI and SWI _w/oPDT , respectively, p = 0.0001). In group SWI _w/oPDT , only 1.5 % (2/131 vs. 5/25; p = 0.001) Candida spp were isolated from SWI. The infection-related in-hospital mortality was high in groups PDT + SWI vs. SWI _w/oPDT (20 % vs. 0 %, respectively; p = 0.0001). The statistical analysis did not demonstrate any correlation between time of performing PDT and occurrence of SWI.

Conclusions

There was a high incidence of microbial cross-infection from the PDTs to the sternal wounds in our study. We did not detect any correlation between the time of performing PDT and occurrence of SWI. According to our data, PDT seems to increase the incidence of SWI, especially caused by Candida spp., after cardiac surgery, which results in a prolonged hospital stay. Therefore, early antifungal prophylaxis after a PDT might be reasonable in high-risk patients on long-term mechanical ventilation if there is an impending SWI.

【 授权许可】

   
2015 Tewarie et al.

【 图 表 】

Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4.

Fig. 5.

Fig. 6.

【 参考文献 】

• [1]Diez C, Koch D, Kuss O, Silber RE, Friedrich I, Boergermann J. Risk factors for mediastinitis after cardiac surgery - a retrospective analysis of 1700 patients. J Cardiothorac Surg. 2007; 2:23. BioMed Central Full Text
• [2]Hollenbeak CS, Murphy DM, Koenig S, Woodward RS, Dunagan WC, Fraser VJ. The clinical and economic impact of deep chest surgical site infections following coronary artery bypass graft surgery. Chest. 2000; 118(2):397-402.
• [3]Ridderstolpe L, Gill H, Granfeldt H, Ahlfeldt H, Rutberg H. Superficial and deep sternal wound complications: incidence, risk factors and mortality. Eur J Cardiothorac Surg. 2001; 20(6):1168-75.
• [4]Salehi Omran A, Karimi A, Ahmadi SH, Davoodi S, Marzban M, Movahedi N et al.. Superficial and deep sternal wound infection after more than 9000 coronary artery bypass graft (CABG): incidence, risk factors and mortality. BMC Infect Dis. 2007; 7:112. BioMed Central Full Text
• [5]Gardlund B, Bitkover CY, Vaage J. Postoperative mediastinitis in cardiac surgery - microbiology and pathogenesis. Eur J Cardiothorac Surg. 2002; 21(5):825-30.
• [6]Mekontso-Dessap A, Kirsch M, Brun-Buisson C, Loisance D. Poststernotomy mediastinitis due to Staphylococcus aureus: comparison of methicillin-resistant and methicillin-susceptible cases. Clin Infect Dis. 2001; 32(6):877-83.
• [7]Modrau IS, Ejlertsen T, Rasmussen BS. Emerging role of Candida in deep sternal wound infection. Ann Thorac Surg. 2009; 88(6):1905-9.
• [8]Mossad SB, Serkey JM, Longworth DL, Cosgrove DM, Gordon SM. Coagulase-negative staphylococcal sternal wound infections after open heart operations. Ann Thorac Surg. 1997; 63(2):395-401.
• [9]Munoz P, Menasalvas A. Bernaldo de Quiros JC, Desco M, Vallejo JL, Bouza E. Postsurgical mediastinitis: a case-control study. Clin Infect Dis. 1997; 25(5):1060-4.
• [10]San Juan R, Chaves F, Lopez Gude MJ, Diaz-Pedroche C, Otero J, Cortina Romero JM et al.. Staphylococcus aureus poststernotomy mediastinitis: description of two distinct acquisition pathways with different potential preventive approaches. J Thorac Cardiovasc Surg. 2007; 134(3):670-6.
• [11]Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control. 1988; 16(3):128-40.
• [12]Pittet D, Monod M, Suter PM, Frenk E, Auckenthaler R. Candida colonization and subsequent infections in critically ill surgical patients. Ann Surg. 1994; 220(6):751-8.
• [13]Playford EG, Webster AC, Sorrell TC, Craig JC. Antifungal agents for preventing fungal infections in non-neutropenic critically ill patients. Cochrane Database Syst Rev. 2006;(1):Cd004920. doi:10.1002/14651858.CD004920.pub2.
• [14]Byhahn C, Rinne T, Halbig S, Albert S, Wilke HJ, Lischke V et al.. Early percutaneous tracheostomy after median sternotomy. J Thorac Cardiovasc Surg. 2000; 120(2):329-34.
• [15]Hubner N, Rees W, Seufert K, Bockelmann M, Christmann U, Warnecke H. Percutaneous dilatational tracheostomy done early after cardiac surgery--outcome and incidence of mediastinitis. Thorac Cardiovasc Surg. 1998; 46(2):89-92.
• [16]Stamenkovic SA, Morgan IS, Pontefract DR, Campanella C. Is early tracheostomy safe in cardiac patients with median sternotomy incisions? Ann Thorac Surg. 2000; 69(4):1152-4.
• [17]Westphal K, Byhahn C, Rinne T, Wilke HJ, Wimmer-Greinecker G, Lischke V. Tracheostomy in cardiosurgical patients: surgical tracheostomy versus ciaglia and fantoni methods. Ann Thorac Surg. 1999; 68(2):486-92.
• [18]Park H, Kent J, Joshi M, Zhu S, Bochicchio GV, Henry S et al.. Percutaneous versus open tracheostomy: comparison of procedures and surgical site infections. Surg Infect (Larchmt). 2013; 14(1):21-3.
• [19]Sun L, Boodhwani M, Baer H, McDonald B. The association between tracheostomy and sternal wound infection in postoperative cardiac surgery patients. Can J Anaesth. 2013; 60(7):684-91.
• [20]Provan JL, Austen WG. The role of elective tracheostomy after open-heart surgery. Ann Thorac Surg. 1966; 2(3):358-67.
• [21]Marshall RD. A review of the management of 140 elective tracheostomies following open-heart surgery. Thorax. 1969; 24(1):78-83.
• [22]Diehl JL, El Atrous S, Touchard D, Lemaire F, Brochard L. Changes in the work of breathing induced by tracheotomy in ventilator-dependent patients. Am J Respir Crit Care Med. 1999; 159(2):383-8.
• [23]Nieszkowska A, Combes A, Luyt CE, Ksibi H, Trouillet JL, Gibert C et al.. Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients. Crit Care Med. 2005; 33(11):2527-33.
• [24]Bacchetta MD, Girardi LN, Southard EJ, Mack CA, Ko W, Tortolani AJ et al.. Comparison of open versus bedside percutaneous dilatational tracheostomy in the cardiothoracic surgical patient: outcomes and financial analysis. Ann Thorac Surg. 2005; 79(6):1879-85.
• [25]Gaudino M, Losasso G, Anselmi A, Zamparelli R, Schiavello R, Possati G. Is early tracheostomy a risk factor for mediastinitis after median sternotomy? J Card Surg. 2009; 24(6):632-6.